Maximal-Effort Cytoreductive Surgery for Ovarian Cancer Patients with a High Tumor Burden: Variations in Practice and Impact on Outcome.

BACKGROUND: This study aimed to compare the outcomes of two distinct patient populations treated within two neighboring UK cancer centers (A and B) for advanced epithelial ovarian cancer (EOC). METHODS: A retrospective analysis of all new stages 3 and 4 EOC patients treated between January 2013 and December 2014 was performed. The Mayo Clinic surgical complexity score (SCS) was applied. Cox regression analysis identified the impact of treatment methods on survival. RESULTS: The study identified 249 patients (127 at center A and 122 in centre B) without significant differences in International Federation of Gynecology and Obstetrics (FIGO) stage (FIGO 4, 29.7% at centers A and B), Eastern Cooperative Oncology Group (ECOG) performance status (ECOG < 2, 89.9% at centers A and B), or histology (serous type in 84.1% at centers A and B). The patients at center A were more likely to undergo surgery (87% vs 59.8%; p < 0.001). The types of chemotherapy and the patients receiving palliative treatment alone were equivalent between the two centers (3.6%). The median SCS was significantly higher at center A (9 vs 2; p < 0.001) with greater tumor burden (9 vs 6 abdominal fields involved; p < 0.001), longer median operation times (285 vs 155 min; p < 0.001), and longer hospital stays (9 vs 6 days; p < 0.001), but surgical morbidity and mortality were equivalent. The independent predictors of reduced overall survival (OS) were non-serous histology (hazard ratio [HR], 1.6; 95% confidence interval [CI] 1.04-2.61), ECOG higher than 2 (HR, 1.9; 95% CI 1.15-3.13), and palliation alone (HR, 3.43; 95% CI 1.51-7.81). Cytoreduction, of any timing, had an independent protective impact on OS compared with chemotherapy alone (HR, 0.31 for interval surgery and 0.39 for primary surgery), even after adjustment for other prognostic factors. CONCLUSIONS: Incorporating surgery into the initial EOC management, even for those patients with a greater tumor burden and more disseminated disease, may require more complex procedures and more resources in terms of theater time and hospital stay, but seems to be associated with a significant prolongation of the patients overall survival compared with chemotherapy alone.

Case report: Spontaneous remission of synchronous endometrial and ovarian cancers following pregnancy.

Introduction: Endometrial cancer is one of the most common malignancies affecting women. It is uncommonly diagnosed in young women, particularly in the absence of abnormal vaginal bleeding symptoms. Case presentation: A 28-year-old woman was referred to our department with lower abdominal pain. Transvaginal ultrasound showed a complex right adnexal mass with mixed echogenicity. Magnetic resonance imaging (MRI) identified a right-sided, torted, cystic solid ovarian mass, and a polypoid lesion in the uterine cavity. Diagnosis: Following multidisciplinary team advice, hysteroscopic transcervical resection of endometrial polypoid mass and laparoscopic right salpingo-oophorectomy was performed. Histopathologic assessment of the endometrial tissue showed changes consistent with grade 1 endometrioid endometrial carcinoma, while the right ovarian mass showed a well-differentiated endometrioid carcinoma. Intervention: The patient underwent hormonal treatment and surveillance whilst making a final decision regarding further surgical management. However, the patient stopped hormonal treatment after 2 weeks, went abroad and absconded from treatment for 8 months. On her return, she had conceived naturally and was in the first trimester of pregnancy. Further management was postponed until the patient was 7 weeks postnatal. The patient was not keen on any further surgical management and opted for close surveillance with ultrasound scans and hysteroscopies with endometrial biopsies. All subsequent endometrial biopsies showed normal endometrium, with no evidence of hyperplasia or malignancy. Outcome: To date, the patient remains on a 6-monthly surveillance plan and is considered to have had complete natural remission of her endometrial and ovarian cancers following pregnancy. Conclusion: This unique case demonstrates a natural phenomenon, in which the complete, natural remission of endometrial and ovarian cancers occurred following pregnancy and childbirth. The aetiology may be related to the high progesterone levels occurring in pregnancy.

Diffusion-weighted MR imaging of female pelvic tumors: a pictorial review.

Functional imaging is becoming increasingly important in the evaluation of cancer patients because of the limitations of morphologic imaging, particularly in the assessment of response to therapy. Diffusion-weighted magnetic resonance (MR) imaging has been established as a useful functional imaging tool in neurologic applications for a number of years, but recent technical advances now allow its use in abdominal and pelvic applications. Diffusion-weighted MR imaging studies of female pelvic tumors have shown reduced apparent diffusion coefficient (ADC) values within cervical and endometrial tumors. In addition, this unique noninvasive modality has demonstrated the capacity to help discriminate between benign and malignant uterine lesions and to help assess the extent of peritoneal spread from gynecologic malignancies. Potential pitfalls can be avoided by reviewing diffusion-weighted MR imaging findings in conjunction with anatomic imaging findings. Increasing familiarity with ADC calculation and manipulation software will allow radiologists to provide new information for the care of patients with known or suspected gynecologic malignancies.

Cervical endometriosis: a diagnostic and management dilemma.

Cervical endometriosis is usually a retrospective finding on histology. We describe the diverse symptomatology of the disease, wherein a suspicion of diagnosis may be raised. A series of five patients with cervical endometriosis confirmed on histology was identified. One patient was asymptomatic but examination revealed a mass arising from the cervix. Two patients presented with persistent postcoital bleeding, one patient with intermenstrual bleeding and one patient with both intermenstrual and postcoital bleeding. All patients were followed up with colposcopy and cervical biopsy. Persistence of symptoms determined the mode of treatment which included surgical management in the form of large loop excision of the transformation zone (LLETZ) biopsy in four patients. Cervical endometriosis is a benign condition which may present with symptoms such as persistent post-coital bleeding or intermenstrual bleeding. Colposcopy and cervical biopsy are pivotal to the diagnosis. This condition can be managed expectantly in asymptomatic patients and persistent symptoms may warrant surgery.